Sustainability through funding and leadership: a mixed-methods study of tobacco treatment programs across U.S. National Cancer Institute-designated Cancer Centers

Background: Tobacco cessation markedly improves cancer treatment outcomes. As part of the National Cancer Institute (NCI) Cancer Moonshot, the Cancer Center Cessation Initiative (C3I) funded 52 U.S. National Cancer Institute-designated Cancer Centers to promote the development of sustainable tobacco treatment programs (TTPs) from 2017–2021. The aim of this analysis was to characterize leadership and funding strategies used by centers to address TTP sustainability. Methods: In 2023–2024, TTP leaders at 47/52 C3I centers responded to surveys on sustainability strategies and outcomes. TTP leaders at 20 centers also completed semi-structured interviews on TTP sustainability and adaptation. For quantitative data, descriptive statistics characterized use of implementation strategies, core program elements, and funding sources. For qualitative data, three authors conducted a thematic analysis using the constant comparative method. Using a concurrent triangulation design (QUAL + quan), analytical integration occurred after initial parallel analysis. Results: Analytical integration revealed three core themes: 1) Right-sizing to ensure financial sustainability: in order to sustain funding, TTPs designed program scopes to be sustainable by discontinuing or never starting core program elements that were unaffordable to maintain in their context (e.g., interactive voice response) and instead investing in lower-maintenance elements (e.g. electronic health record changes); 2) Reliance on institutional funding: given significant administrative hurdles, few TTPs (27.7%) were able to bill for services (6.4% sole source of funding, 6.4% majority source). Instead, most relied on institutional support after C3I funding ended (44.7% sole source of funding, 19.2% majority source); and 3) Wide use of leadership engagement strategies: TTPs engaged leadership and maintained their support after funding ended by continuing to meet regularly with leaders and champions (74.5%), aligning reported metrics with leadership priorities (55.3%), and marketing their program internally (66.0%). Two additional qualitative themes on the importance of leveraging institutional prestige and formalizing commitment emerged during analysis. Conclusions: The ability to leverage leadership support and design programs of appropriate scope allowed TTPs to access institutional funding when billing was not feasible. These strategies may be relevant in other implementation contexts, especially in areas where clinical revenue generation is limited. Trial registration: Not applicable.